Ureaplasma parvum causes hyperammonemia presenting as refractory status epilepticus after kidney transplant.

PURPOSE: Alert intensivists about the diagnostic pitfalls arising from hyperammonemia due to Ureaplasma infections in post-transplant patients. MATERIALS AND METHODS: Clinical observation of one patient. CASE REPORT: A 65-year-old female with a medical history of semi-recent kidney transplant was admitted to the Intensive Care Unit for refractory status epilepticus. There were no lesions on brain imaging. Bacterial cultures and viral PCR of cerebrospinal fluid were negative. The first blood ammonia level measured on day 2 was 13 times the normal level, but biological liver tests were normal. The persistence of elevated ammonia levels led to the initiation of symptomatic ammonia lowering-treatments and continuous renal replacement therapy, which led to its decrease without normalization. An Ureaplasma spp infection was then diagnosed. Levofloxacin and doxycyline were administered resulting in normalization of ammonia levels within 48 h. However repeat MRI showed diffuse cortical cytotoxic edema and the patient remained in a minimally conscious state. She eventually died 4 months later from a recurrent infection. CONCLUSION: Ureaplasma infection must be suspected in cases of neurological symptoms associated with hyperammonemia without liver failure, following an organ transplant. Only urgent treatment could improve the prognosis and prevent severe neurological damage or death.

Improved detection and characterization of arterial occlusion in acute ischemic stroke using contrast enhanced MRA.

BACKGROUND AND PURPOSE: To compare the accuracy and utility of contrast enhanced magnetic resonance angiography (MRA) (CEMRA) to Time of Flight MRA (TOF MRA) during detection and evaluation of occlusions on patients diagnosed with acute ischemic stroke (AIS). METHODS: This single-center study was approved by our local institutional research ethics board. From August 2014 to July 2016, 131 consecutive adult patients with confirmed AIS were included. Detection of an arterial occlusion and its characterization were evaluated independently with CEMRA or TOF MRA by two blinded neuroradiologists, then by consensus using all available MR sequences. A Cohen's Kappa coefficient (κ) and intra-class correlation coefficients (ICC) were used to compare the two techniques. RESULTS: There was substantial concordance in the detection of arterial occlusion between CEMRA and TOF MRA (κ = 0.75). TOF MRA was more likely to show an arterial occlusion than CEMRA (63 versus 52 patients respectively). There were 13 and 1 false positive arterial occlusion with TOF MRA and CEMRA respectively, and 1 false negative with TOF MRA. There was excellent concordance between the location of arterial occlusions and CEMRA and TOF MRA [κ = 0.89 (0.72-0.97)]. CEMRA was significantly more likely to allow measurement of the thrombus than was TOF MRA [38 (75%) versus 14 (22%)] (P < 0.0001). CONCLUSIONS: Our study showed that CEMRA imaging detected arterial occlusions better than TOF MRA in AIS patients and more precisely such that thrombus length and location could be known, which improves the patient's management and care.

Increased diagnostic accuracy of giant cell arteritis using three-dimensional fat-saturated contrast-enhanced vessel-wall magnetic resonance imaging at 3 T.

OBJECTIVES: To compare the diagnostic accuracy of 3D versus 2D contrast-enhanced vessel-wall (CE-VW) MRI of extracranial and intracranial arteries in the diagnosis of GCA. METHODS: This prospective two-center study was approved by a national research ethics board and enrolled participants from December 2014 to October 2017. A protocol including both a 2D and a 3D CE-VW MRI at 3 T was performed in all patients. Two neuroradiologists, blinded to clinical data, individually analyzed separately and in random order 2D and 3D sequences in the axial plane only or with reformatting. The primary judgment criterion was the presence of GCA-related inflammatory changes of extracranial arteries. Secondary judgment criteria included inflammatory changes of intracranial arteries and the presence of artifacts. A McNemar's test was used to compare 2D to 3D CE-VW MRIs. RESULTS: Seventy-nine participants were included in the study (42 men and 37 women, mean age 75 (± 9.5 years)). Fifty-one had a final diagnosis of GCA. Reformatted 3D CE-VW was significantly more sensitive than axial-only 3D CE-VW or 2D CE-VW when showing inflammatory change of extracranial arteries: 41/51(80%) versus 37/51 (73%) (p = 0.046) and 35/50 (70%) (p = 0.03). Reformatted 3D CE-VW was significantly more specific than 2D CE-VW: 27/27 (100%) versus 22/26 (85%) (p = 0.04). 3D CE-VW showed higher sensitivity than 2D CE-VW when detecting inflammatory changes of intracranial arteries: 10/51(20%) versus 4/50(8%), p = 0.01. Interobserver agreement was excellent for both 2D and 3D CE-VW MRI: κ = 0.84 and 0.82 respectively. CONCLUSIONS: 3D CE-VW MRI supported more accurate diagnoses of GCA than 2D CE-VW. KEY POINTS: • 3D contrast-enhanced vessel-wall magnetic resonance imaging is a high accuracy, non-invasive diagnostic tool used to diagnose giant cell arteritis. • 3D contrast-enhanced vessel-wall imaging is feasible for clinicians to complete within a relatively short time, allowing immediate assessment of extra and intracranial arteries. • 3D contrast-enhanced vessel-wall magnetic resonance imaging might be considered a diagnostic tool when intracranial manifestation of GCA is suspected.

Rosette-Forming Glioneuronal Tumor of Spinal Cord.

Rosette-forming glioneuronal tumor has recently been included in the World Health Organization classification as a low-grade tumor. It usually occurs in young adults, arising from the fourth ventricular region. The authors describe a rare case of rosette-forming glioneuronal tumor arising from the spinal cord with cerebrospinal fluid dissemination. Magnetic resonance imaging showed a cervical spinal cord tumor, which could be easily misdiagnosed as ependyma or astrocytoma. Surgical total resection was performed, and histopathologic examination made the diagnosis, showing a biphasic neurocytic and glial tumor with neurocytic rosettes. Six months after surgery, the patient had fully recovered.

Long term follow-up of endovascular management of spinal cord arteriovenous malformations with emphasis on particle embolization.

OBJECTIVE: To determine long term safety and efficacy of endovascular treatment of spinal cord arteriovenous malformations (AVMs), with calibrated particle embolization as a firstline approach. METHODS: We reviewed clinical and imaging data of consecutive patients who underwent endovascular treatment for both nidal and fistulous type spinal cord AVMs in our center, from 1990 to 2015. Outcome at the last follow-up was assessed by an independent observer. RESULTS: Embolization of spinal cord AVMs was performed in 61 patients, including 46 (75%) with particles (exclusively in 29 patients), 30 (49%) with cyanoacrylate, and 6 (10%) with combined surgical treatments. Particle embolizations were iterative in 33 patients (median number of sessions 5 (range 3-6)). Neurological deterioration after treatment occurred in 5 patients (cyanoacrylate=4, surgery=1, particles=0; P<0.001). At a median follow-up of 6 years (range 3-13 years), angiographic cure was obtained in 11/61 (18%) patients (nidal type=6/53 (11%), fistulous type=5/8 (63%)). In progressive forms, neurological improvement occurred in 16/28 (57%) patients, stabilized in 9/28 (31%), and worsened in 3/28 (12%). In hemorrhagic forms, the rebleeding rate was 4/14 patient years without standard treatment, 0/322 patient years in partial iterative treatment, and 0/15 patient years in angiographically cured lesions (P=0.001). CONCLUSION: Our study suggests that particle embolization as a firstline therapy to treat spinal cord AVMs is safe and offers long term efficacy, especially for those with small, distal, and multiple shunts. Partial occlusion of the AVM may be sufficient to prevent rebleeding, without the potential risks of complete occlusion. Particle calibration and injection technique, 'one by one', are critical to safety. Cyanoacrylate embolization or surgery remains necessary if particle embolization fails to occlude large shunts.